Provider Demographics
NPI:1376785311
Name:WILSON, TANYA L (BCBA)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 FOREST HILL CT
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-1813
Mailing Address - Country:US
Mailing Address - Phone:240-994-6985
Mailing Address - Fax:
Practice Address - Street 1:1635 FOREST HILL CT
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1813
Practice Address - Country:US
Practice Address - Phone:240-994-6985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1-07-3745103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst